Primary and secondary malignant disease of the liver and fulminant hepatic failure

The association and presentation of malignant disease of the liver with fulminant hepatic failure has been described sporadically, but the absence of a large series has meant that malignancy is rarely considered in the differential diagnosis of such hepatic failure. We describe three cases and review the best documented reports in the literature. Review of 25 patients shows that in most cases, excluding lymphoma, the liver is massively replaced by tumor that often spreads in an intrasinusoidal pattern. The diffuse nature of malignant spread results in a relative failure of diagnostic imaging and thus the diagnosis is frequently made after death, which occurs a mean 7.8 days after hospital admission. Review of the clinical features and investigations in these cases shows that, when hepatomegaly and ascites are present in middle-aged or older patients at the time of admission, malignancy should be considered as the cause. Why the liver should be massively replaced in such patients remains obscure.